Final Home Health Rule Keeps New Payment Model—With a Few APTA-Supported Changes

Although comments from APTA and other stakeholders helped to spark a few positive changes, the final home health (HH) rule released by the US Centers for Medicare and Medicaid Services (CMS) is nearly the same as what was proposed in July, complete with a major shift to an entirely new payment methodology.

That payment system, known as the Patient Driven Groupings Model (PDGM), moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. However, CMS seems to have listened to APTA and others who called for more detailed clinical care groupings and a clarification that therapists will be permitted to use remote patient monitoring. Mandated by the Balanced Budget Act of 2018, the new system commences in January 2020. Meanwhile, according to a CMS fact sheet, home health providers are on track for a 2.2% payment increase in 2019—the first increase in 10 years.

What didn't change from the proposed rule
The PDGM remains fundamentally the same as proposed—a system that classifies 30-day care episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status in 5 major areas—timing, admission source, clinical group, function level, and comorbidity adjustment—and within some of those areas can be assigned to more detailed clinical categories. The combination of categories assigned to a patient is what generates a particular case-mix grouping. The PDGM also eliminates therapy-use thresholds.

What's different in the final rule
APTA and other commenters were particularly concerned about the proposed rule’s lack of specificity in some of the subcategories—particularly the "Medication Management, Teaching, and Assessment" (MMTA) category in the "Clinical Group" bucket. As proposed, the various grouping combinations resulted in 216 case-mix groups (the current home health system offers 153).

However, in response to comments, CMS dumped the MMTA category and replaced it with 7 new clinical subgroups: surgical aftercare, cardiac/circulatory, endocrine, GI/GU, infectious disease/neoplasms/blood-forming diseases, respiratory, and other. The additional groupings expand the possibilities for classification combinations, increasing the number of possible case-mix groupings to 432.

Additionally, in response to APTA and other commenters voicing serious concerns as to how PDGM may impact access to necessary therapy services, CMS stated it “will continue to analyze utilization trends, including therapy visits as reported on home health claims, to identify any issues that may warrant any quality or program integrity intervention.”

"The PGDM remains problematic on several levels, but the expansion of case-mix groupings helps to respond to one of APTA's major criticisms that the system does not adequately describe patient characteristics and care needs," said Kara Gainer, APTA director of regulatory affairs. "The increased case-mix possibilities will help to ensure that home health payment aligns with patient care needs and the cost of care and will better allow CMS to track patterns over time."

What's been clarified in the final rule
The rule as proposed included language around remote patient monitoring; specifically, how it could and couldn't be billed, and who could do it. The proposed rule was less specific on the "who" part of the equation, however, and APTA pressed for clarity from CMS that physical therapists (PTs) will be included among the providers able to conduct remote monitoring. In the final rule, CMS clarified that this is indeed the case, stating that "As therapy goals must be established by a qualified therapist in conjunction with the physician while determining the plan of care, we believe therapists involved in care planning, as well as other skilled professionals acting within their scope of practice, may utilize remote patient monitoring to augment this process."

What's still being considered
CMS has yet to fully work out exactly how medical reviews related to the admission source category would be triggered in the PDGM. APTA had suggested that CMS conduct post-payment review only for home health agencies that have claims that are consistently associated with claim denials, or whose pattern of codes varies dramatically from peers. CMS responded that it appreciated APTA's suggestions and "will consider such metrics in the development of any targeted reviews."

What's next
While the PDGM won't be implemented until 2020—most likely through a months-long rollout process—the $420 million payment increase is set to go into effect in January 2019. APTA will publish a summary of the final rule in the coming weeks. More resources, including webinar recordings on the PDGM, are available at APTA's home health webpage. The complete final rule can be found on the Federal Register website.